Principles of breast reconstruction.pptx
- 1. Principles of Breast Reconstruction Dr Adewunmi O. Lukman Division of Plastic and Reconstructive Surgery 16th February, 2021
- 2. 2 Outline Introduction Timing Immediate Delayed Delayed immediate Techniques Non autologous Autologous Complications Summary 2/16/2021
- 3. 3 Introduction Surgery for breast cancer is not finished until the reconstruction has been completed in those patients who choose to have it. Mastectomy for breast cancer can lead to negative psychological effects on the patient and breast reconstruction, whether immediate or delayed, can provide significant psychosocial benefits 2/16/2021
- 4. 4 Introduction The ultimate goal of breast reconstruction is to produce a breast that satisfies the patient's wishes and matches the contralateral breast, also improving the preoperative breast aesthetics if possible 2/16/2021
- 5. 5 Introduction Indications Contraindications Serious comorbidities Unresectable local chest wall tumor Rapidly progressive uncontrollable metastatic disease 2/16/2021
- 6. 6 Timing Immediate Delayed Delayed-immediate 2/16/2021
- 7. 7 Timing-Immediate Immediate- advantages 1. Potential for a single operation and one period of hospitalization 2. Maximum preservation of breast skin 3. Preservation of the inframammary fold 4. Good-quality skin flaps 5. Better cosmetic results for skin-sparing mastectomy 6. Reduced need for balancing surgery to the contralateral breast 7. Lower costs than delayed reconstruction 2/16/2021
- 8. 8 Timing-Immediate Immediate- disadvantages 1. Limited time for decision-making by patient 2. Increased single operating time 3. Difficulties of coordinating two surgical teams when required 4. Potential in individual patients for complications to result in delay of adjuvant treatment 2/16/2021
- 9. 9 Timing-Delayed Delayed-Advantages 1. Allows unlimited time for decision-making by the patient 2. Avoids any potential delay of adjuvant treatment 3. Avoids detrimental effects of radiotherapy or chemotherapy on the reconstruction 2/16/2021
- 10. 10 Timing-Delayed Delayed-Disadvantages 1. Requires replacement of a larger amount of breast skin 2. Mastectomy flaps may be thin, scarred, contracted or irradiated 3. Mastectomy scar may be poorly positioned 4. May result in a less aesthetically pleasing outcome 5. Requires separate episode of hospitalization 6. Increased treatment cost compared with immediate breast reconstruction 2/16/2021
- 11. 11 Timing-Delayed-Immediate Delayed-immediate breast reconstruction provides some of the benefits of both immediate and delayed breast reconstruction A skin-sparing mastectomy and immediate reconstruction with a tissue expander is performed Once the final pathology is available, patients who do not require adjuvant radiotherapy proceed to immediate breast reconstruction. 2/16/2021
- 12. 12 Timing-Delayed-Immediate Those who require radiotherapy have their expander fully deflated prior to radiotherapy to allow optimal delivery of the radiotherapy, following which the expander is serially re-expanded within a few weeks of completion of radiotherapy to prevent contraction of the skin envelope whilst awaiting delayed reconstruction 2/16/2021
- 13. 13 Techniques Non autologous Breast implants Tissue expanders Autologous human tissue Combined 2/16/2021
- 14. 14 Techniques-Non-autologous Breast reconstruction by tissue expansion involves the serial expansion of chest-wall tissue to replace permanently the skin lost following mastectomy by repeated injections of saline into an inflatable silicone expander placed behind the pectoralis major muscle 2/16/2021
- 15. 15 Techniques-Non-autologous This may either be followed by replacement with a definitive implant once expansion is complete, or in the case of a permanent expandable breast implant that consists of a silicone outer lumen and an expandable saline inner lumen, only the filling port may need removal if it is not integrated into the device 2/16/2021
- 16. 16 Techniques-Non-autologous Indications 1. small non-ptotic breasts 2. bilateral reconstruction, or 3. women who are happy to accept mastopexy or augmentation procedure on the opposite breast 4. minimal scarring 5. unwilling or unfit to undergo autologous tissue reconstruction 2/16/2021
- 17. 17 Techniques-Non-autologous Contraindications 1. Absent pectoralis major muscles (Poland syndrome) 2. Thin chest wall tissues 3. viability of mastectomy skin flap are uncertain 2/16/2021
- 18. 18 Techniques-Non-autologous Timing Immediate Delayed Implant selection weight of removed breast vs volume of implant Disposable sizers partially empty the expander to the size of the contralateral breast 2/16/2021
- 19. 19 Techniques-Non-autologous Intra-op (immediate) skin marking are done, inframammary fold mastectomy is done with skin preservations sub muscular pocket for implant placement is prepared pectoralis major and serratus anterior muscle Alternatively, acellular dermal matrix can be used 2/16/2021
- 20. 20 Techniques-Non-autologous Intra-op (delayed) similar to immediate mastectomy flap is raised and P. major identified Tissue expansion is placed sub muscularly Expansion is commenced 10-14days after wound has healed, 30-120ml of saline 2/16/2021
- 22. 22 Techniques-Non- autologous Breast reconstruction with sub muscular tissue expander. Courtesy of Eva M. Weiler-Mithoff 2/16/2021
- 24. 24 Techniques-Non-autologous Early complications 1. Haematoma 2. infection 3. mastectomy skin flap necrosis 4. wound dehiscence Late complications 1. Implant rupture/deflation 2. capsular contracture 3. implant malposition/ rotation 4. implant rippling 5. extrusion 6. asymmetry 2/16/2021
- 25. 25 Techniques- Autologous Autologous breast reconstruction allows creation of a breast whose texture and appearance match more closely that which has been lost compared with an implant-based reconstruction In addition, the aesthetic result of autologous breast reconstruction tends to improve with time While the latissimus dorsi (LD) and transverse rectus abdominis musculocutaneous (TRAM) flaps remain popular options for breast reconstruction, there is increasing popularity of the deep inferior epigastric artery (DIEP) flap due to its reduced abdominal donor-site morbidity 2/16/2021
- 26. 26 Techniques- Autologous Indications Large ptotic breasts Immediate reconstruction when adjuvant radiotherapy is planned Delayed reconstruction after adjuvant radiotherapy Failed previous implant reconstruction planned aesthetic abdominoplasty 2/16/2021
- 27. 27 Techniques- Autologous (Latissimus dorsi (LD) flap reconstruction) Muscle flap only Musculocutaneous flap Extended musculocutaneous flap (with subcutaneous fat) Pedicled or free flap Indications previous abdominal surgery rendering abdominal flap unsuitable 2/16/2021
- 28. 28 Techniques- Autologous (Latissimus dorsi (LD) flap reconstruction) Contraindications damaged to flap pedicle from previous surgery e.g. thoracotomy, axillary surgery congenital absent of LD muscle Disadvantages scar in the back shoulder stiffness and upper limb impairment 2/16/2021
- 29. 29 Techniques- Autologous (Latissimus dorsi (LD) flap reconstruction) Pre-op planning Confirm the presence of LD muscle skin requirements: 6-9cm width, 20-25cm length Volume- lean back: 200cm続 average back: 400-700cm続 larger back: > values 2/16/2021
- 30. 30 Techniques- Autologous (Latissimus dorsi (LD) flap reconstruction) 2/16/2021
- 31. 31 Techniques- Autologous (Latissimus dorsi (LD) flap reconstruction) 2/16/2021
- 32. 32 Techniques- Autologous (Latissimus dorsi (LD) flap reconstruction) The defect is closed primarily with quilting sutures under, with or without drain Divide the muscle from insertion Divide the thoracodorsal nerve to present unwanted and distracting motion Insetting is done with or without implant 2/16/2021
- 33. 33 Techniques- Autologous (Latissimus dorsi (LD) flap reconstruction) Early 1. Haematoma 2. infection 3. breast skin necrosis 4. partial or complete flap failure 5. wound breakdown Late 1. seroma 2. implant rupture 3. capsular contracture. 2/16/2021
- 34. 34 Breast reconstruction with lower abdominal tissue The lower abdominal pannus is usually an excellent source of tissue for autologous breast reconstruction and leaves an acceptable donor scar as well as serving as a simultaneous aesthetic abdominoplasty 2/16/2021
- 35. 35 Breast reconstruction with lower abdominal tissue Indications Contraindications Previous ligature of flap pedicle previous abdominoplasty previous liposuction (Relative) 2/16/2021
- 36. 36 Breast reconstruction with lower abdominal tissue Vessels Deep superior epigastric artery (internal thoracic aa) Deep inferior epigastric artery (external iliac aa) Superficial epigastric artery (femoral aa) 2/16/2021
- 37. 37 Breast reconstruction with lower abdominal tissue Pedicled- superior epigastric aa Transverse rectus abdominis muscle (TRAM) Free 1. Transverse rectus abdominis muscle (TRAM) 2. Deep inferior epigastric perforator (DIEP) flap 3. Superficial inferior epigastric perforator (SIEA) flap 2/16/2021
- 38. 38 Breast reconstruction with lower abdominal tissue (TRAM flap) 2/16/2021
- 39. 39 Breast reconstruction with lower abdominal tissue (DIEP flap) 2/16/2021
- 42. 42 Techniques- Autologous Other options, free flaps Gluteal region Superior gluteal artery perforator (SGAP) Inferior gluteal artery perforator (IGAP) Gluteal musculocutaneous flap Medial thigh flap Transverse upper gracilis (TUG) Transverse musculocutaneous gracilis (TMG) Reubens flap (deep circumflex iliac aa) 2/16/2021
- 43. 43 Techniques- Autologous Early 1. Thrombosis of the arterial or venous anastomosis 2. haematoma 3. partial or total flap loss 4. fat necrosis 5. wound breakdown 6. infection of prosthetic mesh if used Late complications 1. donor-site bulge 2. hernia 3. reduced abdominal strength 2/16/2021
- 44. 44 Finishing touches Surgery for the reconstructed breast size or shape adjustment: liposuction, mastopexy, augmentation Lipomodelling Surgery for the contralateral breast Mastopexy, reduction, augmentation Surgery to the flap donor site scar revision, repair of hernia, liposuction, lipofilling, Tx of seroma 2/16/2021
- 45. 45 Nipple-areola reconstruction (NAC reconstruction) Nipple composite graft local flap Areola full thickness skin grafting- areola, labium major Tattooing 2/16/2021
- 46. 46 Summary Breast reconstruction plays a significant role in the woman's physical, emotional and psychological recovery from breast cancer. Even the best reconstruction will not be able to replace the natural breast that has been lost. Surgical options for reconstruction include the use of tissue expanders or breast implants and the use of autologous tissue. The most commonly used surgical techniques are tissue expansion, LD musculocutaneous flap with or without implant, lower abdominal tissue and other free tissue transfers 2/16/2021
- 47. 47 Summary Nippleareola reconstruction leads to increased patient satisfaction with breast reconstruction Due to the variable needs of individual patients, the reconstructive surgeon must be able to provide the full range of reconstructive options 2/16/2021
- 49. 49 References J. Michael Dixon: Breast Surgery, a companion to specialist surgical practice, 5th edition Charles H. Thorne: Grabb and Smiths Plastic Surgery, 7th edition Charles F. Brunicardi: Schwartzs principles of Surgery, 10th edition 2/16/2021